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Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 44-46

Adherence to antidepressants

Department of Pharmacy, Clear Lake Regional Medical Center, 8201 W. Bellfort Houston, USA

Date of Web Publication9-May-2013

Correspondence Address:
Abimbola Farinde
Clear Lake Regional Medical Center, 8201 W. Bellfort Houston
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2045-080X.111581

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While major depression is considered a frequent mental illness there are ongoing reports of high non-adherence to antidepressant medications which places suffers at high risk for relapse, recurrence, or greater impairment,. The World Health Organization (WHO) defines adherence as the extent to which a person's behavior (e.g. taking medications) can align with the agreed recommendations of a health care provider. Unfortunately while patient may recognize the importance of adherence to antidepressant medications the majority of patients do not adhere to their prescribed antidepressants. Some of the factors that may contribute to or lead to non-adherence include knowingly or unknowingly missing doses, taking extra doses, delaying administration times, or taking drug holidays. Pharmacists have the unique ability to deter non-adherence through the performance of continuous assessment and monitoring of adherence in this population given these accessibility. Additionally, pharmacists are able to develop therapeutic alliances with patients that can help to increase the likelihood of achieving positive patient outcomes. Antidepressant non-adherence can be viewed as a significant public health concern so it is important for patients to be educated about the importance of adherence, and health care professionals should be aware of factors or patient characteristics that can serve as barriers to non-adherence.

Keywords: Antidepressants, adherence, pharmacist′s role

How to cite this article:
Farinde A. Adherence to antidepressants. Arch Pharma Pract 2013;4:44-6

How to cite this URL:
Farinde A. Adherence to antidepressants. Arch Pharma Pract [serial online] 2013 [cited 2019 Aug 24];4:44-6. Available from: http://www.archivepp.com/text.asp?2013/4/1/44/111581

  Introduction Top

Major depression is one of the most frequent mental illnesses observed in approximately 40% of primary care patients. [1] Major depression often remains untreated due to poor recognition, which can be potentially fatal. [2] According to the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision (DSM-IV-TR), major depressive disorder (MDD) is characterized by the presence of at least five or more symptoms for a duration of 2 weeks. [2],[3] The severity of the symptoms produce a significant impairment in an individual's quality of life and ability to perform routine activities. [2],[3],[4] Based on the symptoms clusters, depression can be divided into the following five stages: Cognitive symptoms (e.g., memory loss, slowed thought or decreased attention/concentration), vegetative symptoms (e.g., increased or decreased sleep, altered appetite or weight, psychomotor movement), physical symptoms (e.g., fatigue, muscle tension and pain), behavioral symptoms (e.g., social withdrawal, loss of interest in usual activities, crying, weeping) and emotional symptoms (e.g., feelings of guilt, worthlessness, suicidal ideation or behavior). [2],[4],[5]

Depression can present at any age, but its incidence is twice higher among women than among men. [5],[6],[7] The outcome of depression therapy is based on thorough initial assessment, which is the prime criteria [8] for the selection of antidepressants. [9] There are more than 20 antidepressants available in the market. [9] In addition to the beneficial effects of antidepressants, some unwanted effects may act as a main barrier to depression therapy. There are continuing reports of high non-adherence, which increase the risk of relapse, recurrence of depression and greater impairment. [9] According to the World Health Organization (WHO), adherence is defined as the extent to which a person's behavior (e.g., taking medication, following a diet or implementing lifestyle change) aligns with the agreed recommendations of a health care provider. Adherence refers to patients' will or desire to take medicine according to the prescribed dosage, times and frequency. [10] It is estimated that nearly half of the patients are not adherent to their prescribed antidepressants. [10] This thus makes depression therapy more challenging, with a higher relapse rate (approximately 85%). [11] Although patients may recognize that adherence to antidepressant treatment is important for the prevention of recurrence, majority of the patients do not adhere to their antidepressant treatments as prescribed. [11] A retrospective study conducted by Prukkanone and colleagues has used the medication possession ratio (MPR) to measure adherence to antidepressants over a period of 6 months. The overall MPR ( >80%) for individuals who were attending the facility at least twice was 41%, and adherence was as low as 23%. This thus resulted in poor clinical and higher economic outcomes. [12] It is assumed that the common factors that may influence treatment adherence might include the presence of co-morbid illness, patient characteristics, patient's attitudes and patient education. [13],[14] While there is a strong perception that continuation of antidepressant treatment can reduce the odds of relapse, the rate of non-adherence among depressed patients continues to be high. [15]

The issue of medication non-adherence as it relates to the ongoing use is a common problem because patients may not abide by the recommendations that are made by prescribers for proper administration. Patients may either knowingly or unknowingly miss doses, take extra doses, delay the time of administration or take drug holidays at their own discretion. [16] The adoption of inconsistent medication-taking behavior has the potential to progress from early discontinuation, which will lead to poor medication compliance. [16] Because adherence rates to antidepressants can be affected by many factors, it is important for clinicians to evaluate patient profiles to include patient-related disease, treatment characteristics and attributes of the healthcare system. For example, patient-related characteristics that can be associated with non-adherence are ethnicity, socioeconomic status or lack of social support. [17] The lack of awareness of these factors can only serve to perpetuate non-adherence, which can become a major contributing factor to the overall burden of depression. [18] In order to improve the probability of adherence, clinicians must be cognizant of patient-specific factors that serve as barriers and devise methods to overcome the same. Pharmacists are recognized as health care professionals that are most readily accessible to patients and, as a result, can help to improve adherence among patients thus benefiting patient's mental health. [19] Community pharmacists have been shown to improve patients wellbeing with conditions such as hypertension and diabetes, and they have been shown to be instrumental in assessing and monitoring adherence among depressed patients. [19],[20]

The development of a therapeutic alliance between the clinician and the patient can help to increase the likelihood of achieving adherence to antidepressant therapy, which is an essential component of positive patient outcomes. A study conducted by Demyttenaere and colleagues found that relationship dynamics have the potential to influence adherence immediately following medication initiation, but patients' beliefs about treatment and depression can be a more robust predictor as treatment progresses. Patients who possess more favorable beliefs about medications can be found to be more adherent to long-term antidepressant maintenance treatment. [21] The adoption of adherence-enhancing strategies can help to address the vulnerabilities that may exist during the course of treatment. [21] The American Psychiatric Association recommends that patients should continue their antidepressant medication for at least 4-9 months after the resolution of depressive symptoms, but, with more than 50% of the patients discontinuing their medications during the first month, it is imperative that clinicians work closely with patients to promote the benefits of adherence. [22]

In conclusion, antidepressant non-adherence can be viewed as a significant public health concern that clinicians must be fully aware of whenever a patient is initiated on therapy. It is important for patients to be educated on the risks and benefits of non-adherence and strategies that can be taken to increase the likelihood of compliance. The presence of patient-related characteristics that may serve as barriers to adherence should be identified early on and addressed accordingly. The involvement of pharmacists as part of the multidisciplinary team can help to improve adherence through medication management, patient education and close monitoring of ongoing therapy.

  References Top

1.World Health Organization [WHO]. Depression. What is depression? Retrieved from http://www.who.int/mentalhealth/management/depression/definition/en/. [Last accessed on 2008].  Back to cited text no. 1
2.Edmunds MW, Mayhew MS. Pharmacology for the Primary Care Provider. 3 rd ed. Mosey, Inc; 2009.  Back to cited text no. 2
3.American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders, 4 th ed. 2000.  Back to cited text no. 3
4.Sun G, Hsu M, Moyle W, Lin M, Creedy D, Venturato L. Mediating roles of adherence attitude and patient education on antidepressant use in patients with depression. Perspect Psychiatr Care 2011;47:13-22.  Back to cited text no. 4
5.Thomas H, Chan T. Assessment and management of depression in primary care settings. Nursing Older People 2012;24:32-40. Puri BT. Texbook of Psychiatry. 3 rd ed., London: Churchill, Livingson; 2011.  Back to cited text no. 5
6.Maughan B, Collishaw S, Stringaris A. Depression in childhood and adolescence. J Can Acad Child Adolescent Psychiatry 2013;22:35-40.  Back to cited text no. 6
7.Sclar D, Robison L, Schmidt J, Bowen K, Castillo L, Oganov A. Diagnosis of depression and use of antidepressant pharmacotherapy among adults in the United States. Clinical Drug Investig 2012;32:139-44.  Back to cited text no. 7
8.Servellen G, Heise B, Ellis R. Factors associated with antidepressant medication adherence and adherence enhancement programmes: A systematic literature review. Mental Health In Family Med 2011;8:255-71.  Back to cited text no. 8
9.Murata A, Kanbayashi T, Shimizu T, Miura M. Risk factors for drug nonadherence in antidepressant-treated patients and implications of pharmacist adherence instructions for adherence improvement. Patient Preference Adherence 2012;6:863-9.  Back to cited text no. 9
10.World Health Organization. Adherence to Long-Term Therapies: Evidence for action. Geneva, Switzerland: World Health Organizationl 2003.  Back to cited text no. 10
11.Sun G, Hsu M, Moyle W, Lin M, Creedy D, Venturato L. Mediating roles of adherence attitude and patient education on antidepressant use in patients with depression. Perspect Psychiatr Care 2011;47:13-22.  Back to cited text no. 11
12.Prukkanone B, Vos T, Burgess P, Chaiyakunapruk N, Bertram M. Adherence to antidepressant therapy for major depressive patients in a psychiatric hospital in Thailand. BMC Psychiatry 2010;10:64-8.  Back to cited text no. 12
13.Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Patient adherence in the treatment of depression. British Journal of Psychiatry 2002;180:104-9.  Back to cited text no. 13
14.Chakraborty K, Avasthi A, Kumar S, Grover S. Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment. Social Psychiatry Psychiatr Epidemiol 2009;44:482-8.  Back to cited text no. 14
15.Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: A systematic review. Lancet 2003;361:653-61.  Back to cited text no. 15
16.Chong W, Aslani P, Chen T. Effectiveness of interventions to improve antidepressant medication adherence: A systematic review. Int J Clin Pract 2011;65:954-75.  Back to cited text no. 16
17.van Dijk L, Heerdink ER, Somai D, van Dulmen S, Sluijs EM, de Ridder DT, et al. Patient risk profiles and practice variation in nonadherence to antidepressants, antihypertensives and oral hypoglycemics. BMC Health Services Res 2007;7:51.  Back to cited text no. 17
18.Madsen J, McQuaid J, Craighead W. Working with reactant patients: Are we prescribing nonadherence? Depression Anxiety 2009;26:129-34.  Back to cited text no. 18
19.Rubio-Valera M, Serrano-Blanco A, Travé P, Teresa Peñarrubia-María M, Ruiz M, Pujol M. Community pharmacist intervention in depressed primary care patients (PRODEFAR study): Randomized controlled trial protocol. BMC Public Health 2009;9:284-91.  Back to cited text no. 19
20.Machado M, Bajcar J, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions: Part II: Systematic review and meta-analysis in hypertension management. Ann Pharmacother 2007;41:1770-81.  Back to cited text no. 20
21.Demyttenaere K, Enzlin P, Dewe W, Boulanger B, De Bie J, De Troyer W, et al. Adherence with antidepressants in a primary care setting, 1: Beyond lack of efficacy and adverse events. J Clin Psychiatry 2001;62:30-3.  Back to cited text no. 21
22.Castle T, Cunningham M, Marsh G. Antidepressant medication adherence via interactive voice response telephone calls. Am J Manag Care 2012;18:e346-55.  Back to cited text no. 22

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